Polio Australia encourages every polio survivor living in Australia (whether you contracted polio in Australia or overseas) to join the Australian Polio Register. Our strength lies in our numbers – please help us to get you the services you need by completing the form below.

You can also download a PDF version of the Australian Polio Register Form if you (or a family member / friend without internet access) would prefer to complete the form by hand and mail it to: Polio Australia, PO Box 500, East Kew Vic 3102.

Before completing the Australian Polio Register Form please check this page to make sure that you haven’t already submitted a Registration (be aware that an existing entry will only appear on that page if you have previously given Polio Australia permission to publish your polio details). Note that the only way to include your details on the Register is via the online or downloadable forms on this page – being a member of a State Polio Network or a local Polio Support Group, or accessing a polio service (such as Polio Services Victoria), does not automatically add your details to the Register.


* indicates a required field

* Your Given Names

* Your Family Name (in CAPITAL LETTERS please)

Maiden Name (if applicable - CAPITAL LETTERS please)

* Sex
MaleFemale

* Year that you were born

* Year that you contracted polio

Age when you contracted polio (years and months)
   

Location (suburb and/or town) where you contracted polio, including Australian State/Territory if applicable
   

Country where polio contracted (only complete if not Australia)

* Were you hospitalised when you contracted polio?
YesNoDon't Know

If "Yes", which Hospital(s) (if known)?

* In which State/Territory are you currently living?

* Are you a member of your State Polio Network?
YesNo

If you belong to more than one State Network, please indicate the additional States here

* If you are not a member of your State Polio Network, would you like to be put in touch with your State organisation?
YesNoNot Applicable

If you answered "Yes", please provide your postal address and phone number(s) here (not published)

* Please tell us how you first heard about the Australian Polio Register (additional details can be provided below)

Please include any other details here regarding how you heard about the Australian Polio Register

If you wish to include any additional comments with your registration please enter them here (not published)

* Your email address (not published)

* If you are happy to have your name and polio details published # on this site, please click "Yes".
* If you click "No" instead, your collected data will only be published in anonymous aggregate form.
*

YesNo

# If you click "Yes", only these details are published: family name, maiden name (if applicable), given names, birth year, year in which polio contracted, age at which polio contracted, and location where polio contracted.

Thank you for completing this form. To now send your details through to Polio Australia, please click in the white box below to confirm you are a human (a green tick will appear), then click the "Submit your details" button beneath.

Once the form has been successfully submitted, a copy of the details that you entered will also be emailed to you for your records.


After submitting the form you should see a message in a box with a green border saying “Your registration was submitted successfully. Thanks.”, and you will be re-directed to a “thank you” page. If you instead receive a “validation errors occurred” message, please check your entries – particularly ensuring that all required questions (those marked with *) have been answered – then resubmit the form.

If you strike a difficulty in submitting this form that you cannot resolve, you can download a PDF version of the Australian Polio Register Form to complete and mail to Polio Australia. You can also contact us by phone or email, or by completing our contact form, to let us know about the difficulty you experienced.